Pharmacies had a record flu jab season – but policy missteps got in the way

Community pharmacies delivered a record number of flu vaccinations this winter, but the service was beset by organisational hurdles that stopped even greater uptake. By Saša Janković

Pharmacies continue to prove their vital role in the national influenza vaccination programme, with their involvement and customer take-up growing year on year.

Data from the UK Health Security Agency (UKHSA) shows that the NHS delivered more than 20 million flu vaccines this winter season, with PSNC figures revealing that almost five million of those have been administered as part of the community pharmacy Flu Vaccination Service 2022/23 since 1 September 2022.*

This builds on a total of 4,851,608 jabs administered by community pharmacists under the NHS Advanced service by the end of March 2022, according to NHS data.

“Word is spreading that pharmacy is open and ready to offer this service,” says Leyla Hannbeck, chief executive of AIMp (Association of Independent Multiple Pharmacies).

“We are seeing increased demand from patients coming and asking for the jab, whereas in previous years we have had to drive the demand by promoting the service.”

Nonetheless, there are some sticking points that meant the service wasn’t able to meet its full potential. “Demand was high at the start of the season, with patients wanting to get in early, but it was difficult to meet some of this demand due to the workforce shortages seen across community pharmacy,” says Ms Hannbeck. “If we had the pharmacists in the sector, we would have been able to vaccinate more of the population than we did.”

There is also a level of vaccine fatigue among patients who, according to Ms Hannbeck, “decided that with all the covid vaccinations they had, they then didn’t want the flu jab as well”.

Not being able to provide both flu and covid vaccines at the same time in all sites was another barrier to uptake. “One thing community pharmacies in England would appreciate is if they can offer a combined entry form for both the covid and flu jab,” says Helga Mangion, policy manager at the NPA.

“Currently, they have to use two platforms and do two separate data entries for both jabs, which is unproductive and inefficient. Community pharmacies also ought to be on a level playing field with other healthcare providers when expression of interests about providing covid vaccinations go out. Up until now, pharmacies are selected to fill in gaps rather than treated as a first line choice by commissioners.”

Eligibility flip-flops

Government tweaks to the programme with regard to eligibility criteria and staggered vaccination timings post-lockdowns also hindered progress.

Securing flu vaccines means ordering almost 12 months before the service starts, so orders were placed in September 2021 and were amendable until February 2022, yet the service guidance did not come out until April 2022. The guidance included the change that patients aged between 50 and 64 were no longer eligible for free NHS vaccinations, a decision that came too late to amend any orders based on anticipating this cohort.

However, the advice changed yet again in July last year, when there was a U-turn that restored free NHS vaccinations to include 50-64 year olds, with the caveat that the service would not begin for this age group until 15 October, almost seven weeks after the rest of the flu service started.

“This reduced demand and led to leftover vaccines at the end of the campaign, which likely means less people were vaccinated”, says Ms Hannbeck. “It really hinders our ability to plan for any upcoming flu campaigns as we don’t know how many flu vaccines to order.”

Alastair Buxton, PSNC’s director of NHS Services, agrees that the Government’s decision to implement a later start for the 50-64 year old cohort was “one aspect of this season which did not assist with optimal provision of the programme”.

He adds that while the U-turn on inclusion of 50-64 year olds in the programme was a welcome decision from a public health perspective, such last minute decisions do not represent “competent management of public health programmes” by the state.

“We hope lessons will be learned and an early decision will be made on eligible cohorts for the 2023/24 season as soon as possible,” he says. “PSNC is regularly reminding NHS and DHSC colleagues of the importance of a decision being made in a timely manner, following the recent publication of the JCVI guidance for 2023/24.”

Ms Mangion says that the NPA is also “calling on the Government to routinely include the over-50s in the eligibility criteria” – a move to create stability that would be welcomed by community pharmacists delivering the vaccination programme.

“Government flip-flopping on eligibility created a lot of extra work,” says Nat Mitchell, pharmacist and director of JWW Allison & Sons Chemist in Cockermouth, Cumbria. “We had ordered on the basis that over-50s would be getting the jabs, then we were told they wouldn’t, so we knocked our order back. Then it turned out they were included, so we had to go back to the wholesaler, which meant some of our vaccines came later.”

Ifti Khan, pharmacy superintendent at Well Pharmacy, says that while the distribution of vaccines to the company’s pharmacy teams was “really smooth”, it faced the same sector-wide challenges as others. “These centred around late changes to the inclusion criteria, vaccine hesitancy, and the fact that the national booking site was only opened up for pharmacies that were also doing covid boosters,” he says – a hurdle also noted by Andrew Hobson, superintendent pharmacist at D&M Gompels Pharmacy in Wiltshire.

“Demand was diminished for us mainly because locally the covid clinics were also doing flu vaccinations at the same time, so people went there,” says Mr Hobson. “The result is that we’re probably 25 per cent down on previous years where we had been increasing our take-up by about 15 per cent in the two to three years before that, and we ended up with quite a bit of stock left over.”

Private flu jabs down

“There’s also been a big drop in the number of private flu jabs we have done this season,” says Mr Hobson, “especially in people under 60-65 who have had two or maybe three covid jabs and started to get vaccine fatigue.”

Indeed, towards the end of the season, the multiples began to slash their prices for private flu vaccinations or even give them away for free in order to use up stock.

During a cost of living crisis, this has its benefits, according to Ms Mangion. “The pandemic has increased the number of patients considering taking the flu vaccination in addition to the covid vaccination booster, and as they may not fit the eligibility for free vaccination, patients need to seek this service privately,” she says.

“We are already seeing a number of patients going without their prescriptions due to the cost of living crisis [and] in response you may find a number of pharmacies provide the private flu service at a lower price point to reflect patient circumstances.”

However, while this is great for public health, there is a potential downside. Ms Hannbeck says that giving away private allocations for free “could have a huge impact on the pharmacy service in the future, as it appears that we have the ability to offload this stock with no consequence. Patients may well wait in future years to see if they can get a free vaccination at the end of the season, rather than getting it at the appropriate time, well before flu starts to circulate.”

Gompels Pharmacy offers both NHS and private flu vaccinations, and although Mr Hobson says the pharmacy did decide to offer its extras for free, he agrees that “there’s always a concern that NHSE might not see the value of what pharmacy is doing”.

For Mr Mitchell, there’s also the reducing bottom line to consider. “The margin on private flu jabs now is so low independents are really just doing it as a service rather than to make money as you simply can’t compete with the multiples,” he says.

Need for change

With community pharmacies under immense pressure, and to help the flu service grow even further, CCA head of policy Dr Nick Thayer says there is “a need for key changes, including pharmacy technicians administering vaccines working under patient group directions”.

However, he adds: “It is difficult to ignore the chronic underfunding of the sector upon which this vital access to vaccination is built. It is fantastic to see the role of community pharmacy becoming a core part of public health in this country [but] to continue to see the growing role of community pharmacy, action needs to be taken to address the broken funding model.”

The CCA calculates that the community pharmacy sector should be able to provide an additional 10 million vaccinations every year in England, and Dr Thayer says there is no need for it to stop there. “Commissioning all recommended vaccinations from community pharmacy will shift work from other parts of the NHS, especially GP practices,” he says.

“This will also increase the routes to vaccination and help maximise uptake, particularly in deprived communities. Community pharmacy can and should be the natural home for vaccination.”

*As of 15 Feb 2023, PSNC data shows a total of 4,919,130 jabs administered as part of the community pharmacy Flu Vaccination Service 2022/23 since 1 September 2022, with the caveat that these only record vaccinations entered into the PharmOutcomes and Sonar systems. Pharmacy contractors don’t have to use these systems, so the final number of vaccinations administered, based on the end of season NHSBSA claim data, is generally higher. https://psnc. org.uk/national-pharmacy-services/ advanced-services/fluvaccination-service/fluvaccination-statistics/